International Journal of Social Psychiatry 2016, Vol. 62(6) 501 –504 © The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764016645624 isp.sagepub.com
E CAMDEN SCHIZOPH
Basaglia’s reforms of Italian psychiatry led to the develop-ment of Community Mental Health Services which replaced the asylums with a remarkable change of perspec-tive. The main aim was to treat patients in the community and no longer in the hospitals. The Italian model and its development influenced similar reforms in some other countries over the years. Also, we believe that it had a major impact on the legal responsibility of psychiatrists in Italy. The management of acute and chronic psychiatric disorders in the community remains a hugely complex and risky task. Italian psychiatrists are responsible to be able to deal with several social and legal issues related to psychi-atric disorders. Moreover, the development of this commu-nity-based model has influenced Courts’ decisions over the decades, and those legal decisions have changed psy-chiatrists’ attitudes as well as their perspectives as dis-cussed in this article.
Law 180/1978 and its impact on
responsibility
After the approval of Law180 in 1978 regarding the disman-tling of psychiatric asylums in Italy (as proposed by Franco Basaglia), Mental Health Centers were developed for treat-ing mentally ill people in the community with an emphasis on possible reduction in rates of inpatient care. These ser-vices are organized in a geographical manner since each urban area is covered by community institutions and resources. This model aims to promote integration and human rights for the mentally ill people on the basis of free-dom to choose their treatment options (Castaldelli-Maia & Ventriglio, 2016). We believe that there exists a stronger relationship between this newer model of mental health care system and legal responsibilities expected of psychiatrists in Italy. This is strongly influenced by cultural values in both fields, since legal responsibilities of psychiatrists might influence the practical organization of such services.
After the enactment of Law 180/1978, Courts’ decisions and judgments in Italy inevitably have influenced the new conceptual framework, oriented on recognizing patients’ freedom, rights and their decisional power, including ‘the
choice to commit suicide’. Although prevention of suicide
remains one of the most important clinical issues for psy-chiatrists, they might not prevent patients from committing suicide if it was their free choice. In fact, on 5 October 1982, Court in Brindisi absolved psychiatrists and nurses
from a Mental Health Department investigation for multi-ple suicides, which had occurred in that hospital because ‘according to Law 180/78’, their clinical competencies and decisions were considered not to be related to patients’ committed suicides.
On 9 June 1993, Court in Bologna absolved psychia-trists who had taken a decision based on clinical grounds not to compulsorily admit a patient who subsequently committed suicide. Similarly, on 27 May 1999, Court in Busto Arsizio absolved the involved psychiatrist who had been charged with manslaughter allegedly on the grounds that they had not adopted adequate safety measures for a patient who subsequently attempted suicide through self-poisoning and managed to jump-off from the ward during the hospitalization. Psychiatrist was judged not to be responsible for ‘free choice’ of the patient in this instance. These judgments considered committed suicides as a result of patient’s free choices, and the role of psychiatrist was judged to be simply related to the delivery of the best evi-dence-based treatment for that patient without any specific control on his harmful behaviors.
Current Italian framework
Like in many countries, legal principles influencing Courts’ judgments and decisions have changed over the years in Italy. Although those acquittals were fully inspired by the new psychiatric reforms which are still in the pro-cess of being established, nowadays the cultural back-ground and the public opinion on the social dangerousness of the mentally ill people are beginning to shift and change.
In fact, Courts have been considering principles from the medical legal responsibility policy (as stated by
Cassazione Penale (Italian Supreme Court-Criminal
Section) on 1 December 2014 and 11 March 2015) includ-ing the obligation for psychiatrists to prevent patients’ dan-gerous behaviors and protect them from committing suicides, homicides, aggressions and so on, even if patients’ adherence to treatments must be discretionary (Cassazione
Penale, 27 November 2008).
This change in perspective of courts’ decisions and judgments clearly states that the obligation lies on the psy-chiatrist to adopt safety measures for patients even if their compliance to the treatments is voluntary: psychiatrists should admit patients compulsorily if needed, even if it is under exceptional circumstances.
Community mental health services and
responsibility of psychiatrists in Italy:
Lessons for the globe
645624ISP0010.1177/0020764016645624International Journal of Social PsychiatryEditorial
research-article2016
502 International Journal of Social Psychiatry 62(6)
We believe that these changes have been strongly influ-enced by cultural and ethical factors including patients’ wishes. Other factors, such as the choice of specific treat-ments, their dosages and possible side effects, are also legally discussed and judged on a legal basis nowadays (Fumadó, Gómez-Durán, Rodríguez-Pazos, & Arimany-Manso, 2015).
Recently, the Cassazione Penale passed judgments on the therapeutic relationship between patients and their psy-chiatrists, patients’ control and rights and patients’ informed consent for treatments and compulsory treatments. In par-ticular, the Cassazione Penale recognized a ‘warranty
position’ for all psychiatrists especially for extreme
situa-tions such as suicide and homicide (Lamsma & Harte, 2015; Terranova & Sartore, 2013). Warranty position is defined by the following points:
1. Although patient’s compliance to treatments is vol-untary, psychiatrists must control and prevent patients’ behavior in order to protect them and the community from harmful consequences.
2. Psychiatrists should prevent suicide when it is due to underlying psychopathology.
3. Psychiatrists should prevent suicide risk adopting adequate safety measures such as compulsory admissions, if needed.
4. Psychiatrists should keep patients under close scru-tiny even if the hospitalization is not compulsory (Cassazione Penale, 12 January 2015).
5. In case of patients’ risky behaviors, psychiatrists cannot justify the lack of safety measures with the aim ‘to save the relationship’ with the patient. On 27 January 2006, Court in Bologna and Cassazione
Penale condemned the involved psychiatrist for
man-slaughter for his patient’s homicide (Terranova & Rocca, 2016). This was a surprising judgment which showed slightly different position and interpretation of the Italian law on the responsibility of psychiatrists in disagreement with Law 180/1978 and its previous statements.
Currently, psychiatrists in Italy may be considered grossly negligent if the patient they are responsible for commits a crime as a result of their psychopathology. Psychiatrists are obliged not only to provide the best treatment option for the patient but also to prevent the patient’s harmful behaviors and protect him from any possible consequence (Cassazione Penale, 28 January 2009). Supreme Court in Italy states that patients’ control should be guaranteed not only during the compulsory treatments but also involuntary treatment. Also that the psychiatrist should be able to predict and prevent crimes related to the mental illness when they are supposed to be
predictable and preventable.
In other words, Italian psychiatrists should be able to make decisions about their patients in a balanced manner,
taking into account patient’s rights and freedom, social con-trol, preventable and predictable crimes along with the ther-apeutic relationship as a core of any psychiatric treatment.
This position has generated a climate of fear among psychiatrists who are fully oriented on the legal conse-quences of their own clinical decisions and may take a
defensive position to avoid legal trials and patients’ crimes
(Catanesi et al., 2010). This framework, thus, goes on to affect psychiatrists’ decision making and has a huge impact on the quality of their work, satisfaction and quality of life. They may, thus, feel very vulnerable in their work and hor-ribly guilty if condemned or investigated for a job-related decision.
Global implications
We believe that such position statements do not take into account the complexity of human behaviors, which are determined by several factors, possibly (but not only) related to patients’ psychopathology (Vandamme, 2009). It is well-recognized that human behavior, including danger-ousness, might be determined by multiple variables at multiple levels (Joyal, Dubreucq, Gendron, & Millaud, 2007).
In some circumstances, psychiatrists in Italy are cur-rently supposed to be able to predict and prevent events and make advance decisions about events which seem to be poorly predictable and preventable in the therapeutic framework. This debate about psychiatrists making advance decisions and patients making advanced direc-tives whether they should be treated or not is a complex one and needs careful ethical consideration globally.
Cendon (2015), a Professor of Law especially well known in Italy for his attention to psychiatric issues, described the current situation as a real ‘fear of law’ in his book ‘The responsibility of psychiatric services’.
It is inevitable that this ‘fear of law’ may have a nega-tive impact on the role of psychiatrists and could lead to a therapeutic relationship based on legal defensive aspects rather than clinical needs. Fiori and Buzzi, two of the most prestigious professors of Italian legal medicine, in 2008, had also argued that this fear will change the focus of med-icine from the evidence-based interventions to the legal aspects with a significant negative influence on clinical procedures and the professionalism of psychiatrists.
Italian psychiatrists reject the ‘obligation to protect and
control’ their patients since it belongs to the older model of
psychiatry based on the asylums.
This social control in the hands of medicine, as argued by Ventriglio and Bhugra (2015), has to be balanced against medicine as a profession and expectations from society and Courts: there are recent concerns about the de-professionalization of psychiatry.
Although medical responsibility does include therapeutic errors due to clinician’s incompetence or/and carelessness
Editorial 503 or/and negligence. Psychiatrists are supposed to be
responsi-ble if patients’ admissions or discharges from the hospital are not adequately supported or patients are not properly kept under close scrutiny during the hospitalization in order to avoid harmful behaviors. In addition, most of time, the hos-pitalization is supposed to be an instrument of control and
prevention.
Since, the Italian mental health care system is based on the community treatment and hospitalizations should be considered as exceptional, psychiatrists need to ensure patients’ control in the community setting as well as pre-dicting and controlling behaviors in patients’ everyday life, which is different from preventing patients’ behav-iors in the asylums. In the community, variables and inter-actions influencing patient’s inter-actions and decisions are unlimited.
Recently, this issue has become hugely relevant in Italy after the approval of Law 9 on 17 February 2012 regarding the dismantling of penitentiary hospitals in which mentally ill offenders are treated because of their social
dangerous-ness. Some authors note that this is a logical step as a
fol-low-up to the Basaglia’s reforms (Casacchia et al., 2015) but it surely involves a large degree of risks for psychia-trists, since they are expected to ensure control and pre-vention for the psychiatric offenders as well.
The way forward
We believe that the role of psychiatry and psychiatrists should be refocused. Control cannot be the core of the psychiatric interventions. It is interesting to see that the control, previously attributed to asylums and institutions, has been handed over for psychiatrists to control their patients. Therapeutic relationship between psychiatrists and their patients should be based on clinical decisions to be shared and discussed. However, patients’ rights and freedom must be considered whenever there is a risky or harmful behavior related to underlying psychopathology (according to the statement from Cassazione Penale, 12 January 2005). Psychiatrists need to work within the law but pressures of social control may take away the clinical therapeutic relationship between them and their patients.
We believe that psychiatrists need to demonstrate clearly the complexity of human behavior and its unpre-dictable aspects: care and control cannot be necessarily combined in the clinical practice. The selection of the ade-quate psychopharmacological and psychotherapeutic treatment for one patient is not a guarantee of control and prediction for another. Competencies and roles of psychia-trists are surely overestimated by the Italian law and soci-ety (Douglas, Guy, & Hart, 2009).
There needs to be a clear agreement between psychia-try and judiciary about competencies and roles of clini-cians regarding the understanding of social dangerousness and instruments of control. It is necessary to develop
standardized protocols and procedures between the department of mental health and police to be applied in cases of violent behaviors. This would lead to a shared responsibility and would involve police and judiciary, which have adequate instruments to ensure social control. This also would greatly improve the quality of work for psychiatrists and their subjective satisfaction, with a reduction in the ‘fear of law’.
This integration between psychiatry and judiciary would require a cultural shift and a complex debate between the institutions, including politicians and policy-makers, health-care providers and judiciary. Approved laws should be also reconsidered on the basis of analyses and unmet needs raised by psychiatrists. In addition, national psychiatric societies should offer clear position statements which are agreed with patients, their families and carers, and communicate these extensively in order to change the public opinion and promote this cultural shift. The professionalism of psychiatry and psychiatrists depends upon an ongoing dialogue with the policymakers as well as patients and their carers and families. The con-tract between society and psychiatry is very strongly cul-turally influenced and needs to be revisited regularly to ensure that patients get the best treatment without fear and prejudices, and psychiatrists as a professional feel valued and not afraid.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article
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Roberto Catanesi1, Adelmo Manna2 and Antonio Ventriglio3
1Department of Legal Medicine, Section of Criminology
and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
2Section of Criminal Law, University of Foggia, Foggia, Italy 3Department of Clinical and Experimental Medicine,
University of Foggia, Foggia, Italy
Corresponding author: Antonio Ventriglio
Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy. via G. Marconi,
n° 3-71041-Crapelle (FG)-Italy.
